Tax Deposit Frequency Authorization

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5 Tax Deposit Frequency Authorization Client Name: For Lookback Period: 2014 (Quarters 3, 4 of 2012 and Quarters 1, 2 of 2013) Employers must pay their payroll taxes on a Next Day, Semi-Weekly or Monthly basis. To determine your tax deposit frequency, the IRS uses your tax liability incurred during the four-quarter lookback period (see example above). For instance, if your liability equaled or exceeded $50,000 during the lookback period, then you are a Semi-Weekly Depositor. If your liability was less than $50,000 during the lookback period, then you are a Monthly Depositor. The only exceptions to this determination are previously required next day tax deposits (i.e., a deposit exceeding $100,000), or if your taxes were previously paid on a semi-weekly basis. Either exception would cause an automatic Semi-Weekly Depositor status. Before Combined Financial Services, Inc. dba Complete Payroll Services can process your payroll, we must know your correct deposit frequency. As such, you must provide us with the necessary documentation, initial the appropriate section, and sign below. If you are unsure of your deposit frequency, we suggest you consult a qualified tax professional. Please note that unless a section is initialed below and this form is properly signed at the bottom, our system will automatically process your payroll as a Semi-Weekly Depositor. ONLY INITIAL THE ONE BOX THAT APPLIES TO YOUR COMPANY Semi-Weekly: I. I either do not meet any of the conditions noted in boxes II through V below, or I previously deposited payroll taxes other than as a Monthly Depositor. As such, we qualify as a Semi-Weekly Depositor. Monthly With Lookback Documentation: II. I am providing copies of our 941s from the lookback period. Since our tax liability during that period was less than $50,000 and we have never deposited taxes differently, we qualify as a Monthly Depositor. Monthly With IRS Letter: III. I am providing a copy of our current Federal Tax Deposit Requirements letter from the IRS. It states that we may follow the monthly rule for our tax deposits and we have not deposited taxes differently. Monthly -- New Business: IV. I started my business during the following month and year, and therefore do not have all of the 941s to meet the lookback requirements. I am providing any 941s that do apply. Since our tax liability during that period was less than $50,000 and we have not deposited taxes differently, we qualify as a Monthly Depositor. (A copy of a completed SS-4 must be attached). Monthly Without Lookback Documentation: V. I do not have the necessary documentation to prove that I am a Monthly Depositor, however, I know my tax liability falls within the guidelines set forth by the IRS.. Printed or Typed Name and Title Company Name as Registered With the IRS Signature (must be authorized to sign for the company noted above) Date Federal ID Number (EIN)

6 Form (Rev. November 2009) Department of the Treasury Internal Revenue Service Taxpayer 1a 8655 Name of taxpayer (as distinguished from trade name) Reporting Agent Authorization 2 OMB No Employer identification number (EIN) 1b 3 Trade name, if any Address (number, street, and room or suite no.) 4 If you are a seasonal employer, check here 5 Other identification number City or town, state, and ZIP code 6 Contact person Reporting Agent 9 Name (enter company name or name of business) 7 Daytime telephone number 8 10 Fax number Employer identification number (EIN) 11 Address (number, street, and room or suite no.) City or town, state, and ZIP code 12 Contact person 13 Daytime telephone number 14 Fax number Authorization of Reporting Agent To Sign and File Returns 15 Use the entry lines below to indicate the tax return(s) to be filed by the reporting agent. Enter the beginning year of annual tax returns or beginning quarter of quarterly tax returns. See the instructions for how to enter the quarter and year. Once this authority is granted, it is effective until revoked by the taxpayer or reporting agent Authorization of Reporting Agent To Make Deposits and Payments 16 Sign Here Use the entry lines below to enter the starting date (the first month and year) of any tax return(s) for which the reporting agent is authorized to make deposits or payments. See the instructions for how to enter the month and year. Once this authority is granted, it is effective until revoked by the taxpayer or reporting agent CT PF 990-T Disclosure of Information to Reporting Agents 17a Check here to authorize the reporting agent to receive or request copies of tax information and other communications from the IRS related to the authorization granted on line 15 and/or line 16 b Check here if the reporting agent also wants to receive copies of notices from the IRS Form W-2 Series or Form 1099 Series Disclosure Authorization 19 Check here to authorize the reporting agent to sign and file state or local returns related to the authorization granted on line 15 and/or line 16 Authorization Agreement I understand that this agreement does not relieve me, as the taxpayer, of the responsibility to ensure that all tax returns are filed and that all deposits and payments are made. If line 15 is completed, the reporting agent named above is authorized to sign and file the return indicated, beginning with the quarter or year indicated. If any starting dates on line 16 are completed, the reporting agent named above is authorized to make deposits and payments beginning with the period indicated. Any authorization granted remains in effect until it is revoked by the taxpayer or reporting agent. I am authorizing the IRS to disclose otherwise confidential tax information to the reporting agent relating to the authority granted on line 15 and/or line 16, including disclosures required to process Form Disclosure authority is effective upon signature of taxpayer and IRS receipt of Form The authority granted on Form 8655 will not revoke any Power of Attorney (Form 2848) or Tax Information Authorization (Form 8821) in effect. I certify I have the authority to execute this form and authorize disclosure of otherwise confidential information on behalf of the taxpayer. Signature of taxpayer 940-PR 941-PR 941-SS PR PR 944-SS CT-1 18a b The reporting agent is authorized to receive otherwise confidential taxpayer information from the IRS to assist in responding to certain IRS notices relating to the Form W-2 series information returns. This authority is effective for calendar year forms beginning. The reporting agent is authorized to receive otherwise confidential taxpayer information from the IRS to assist in responding to certain IRS notices relating to the Form 1099 series information returns. This authority is effective for calendar year forms beginning. State or Local Authorization For Privacy Act and Paperwork Reduction Act Notice, see page 2. Cat. No T Form 8655 (Rev ) Title Date

7 Form 8655 (Rev ) General Instructions Purpose of Form Form 8655 is used to authorize a reporting agent to: Sign and file certain returns; Make deposits and payments for certain returns; Receive duplicate copies of tax information, notices, and other written and/or electronic communication regarding any authority granted; and Provide IRS with information to aid in penalty relief determinations related to the authority granted on Form Authority Granted Once Form 8655 is signed, any authority granted is effective beginning with the period indicated on lines 15 or 16 and continues indefinitely unless revoked by the taxpayer or reporting agent. No authorization or authority is granted for periods prior to the period(s) indicated on Form Where authority is granted for any form, it is also effective for related forms such as the corresponding non-english language form, amended return, (Form 941-X, 941-X(PR), 943-X, 944-X(PR), 945-X, or CT-1X) payment voucher, or deposit coupon. In addition to the returns shown on lines 15 and 16, Form 8655 can be used to provide authorization for Form 944-SP using the entry spaces for Form 944. The form also can be used to authorize a reporting agent to make deposits and payments for other returns in the Form 1120 series, such as Form 1120-C, using the entry space for Form 1120 on line 16. Disclosure authority granted on line 17a is effective on the date Form 8655 is signed by the taxpayer. Any authority granted on Form 8655 does not revoke and has no effect on any authority granted on Forms 2848 or 8821, or any third-party designee checkbox authority. Where To File Send Form 8655 to: Internal Revenue Service Accounts Management Service Center MS 6748 RAF Team 1973 North Rulon White Blvd. Ogden, UT You can fax Form 8655 to the IRS. The number is Additional Information Additional information concerning reporting agent authorizations may be found in: Pub. 1474, Technical Specifications Guide for Reporting Agent Authorizations and Federal Tax Depositors. Rev. Proc You can find Rev. Proc on page 1442 of Internal Revenue Bulletin at Substitute Form 8655 If you want to prepare and use a substitute Form 8655, see Pub. 1167, General Rules and Specifications for Substitute Forms and Schedules. If your substitute Form 8655 is approved, the form approval number must be printed in the lower left margin of each substitute Form 8655 you file with the IRS. Revoking an Authorization If you have a valid Form 8655 on file with the IRS, the filing of a new Form 8655 revokes the authority of the prior reporting agent beginning with the period indicated on the new Form However, the prior reporting agent is still an authorized reporting agent and retains any previously granted disclosure authority for the periods prior to the beginning period of the new reporting agent s authorization unless specifically revoked. If the taxpayer wants to revoke an existing authorization, send a copy of the previously executed Form 8655 to the IRS at the address under Where To File, above. Re-sign the copy of the Form 8655 under the original signature. Write REVOKE across the top of the form. If you do not have a copy of the authorization you want to revoke, send a statement to the IRS. The statement of revocation must indicate that the authority of the reporting agent is revoked and must be signed by the taxpayer. Also, list the name and address of each reporting agent whose authority is revoked. Page 2 Withdrawing from reporting authority. A reporting agent can withdraw from authority by filing a statement with the IRS, either on paper or using a delete process. The statement must be signed by the reporting agent (if filed on paper) and identify the name and address of the taxpayer and authorization(s) from which the reporting agent is withdrawing. For information on the delete process, see Pub Specific Instructions Line 15 Use the YYYY format for annual tax returns. Use the MM/YYYY format for quarterly tax returns, where MM is the ending month of the quarter the named reporting agent is authorized to sign and file tax returns for the taxpayer. For example, enter 09/2008 on the line for 941 to indicate you are authorizing the named reporting agent to sign and file Form 941 for the July September quarter of 2008 and subsequent quarters. Line 16 Use the MM/YYYY format to enter the starting date, where MM is the first month the named reporting agent is authorized to make deposits or payments for the taxpayer. For example, enter 08/2009 on the line for 720 to indicate you are authorizing the named reporting agent to make deposits or payments for Form 720 starting in August 2009 and all subsequent months. Who Must Sign Sole proprietorship. The individual owning the business. Corporation (including a limited liability company (LLC) treated as a corporation). Generally, Form 8655 can be signed by: (a) an officer having legal authority to bind the corporation, (b) any person designated by the board of directors or other governing body, (c) any officer or employee on written request by any principal officer, and (d) any other person authorized to access information under section 6103(e). Partnership (including an LLC treated as a partnership) or an unincorporated organization. Generally, Form 8655 can be signed by any person who was a member of the partnership during any part of the tax period covered by Form Single member LLC treated as a disregarded entity. The owner of the LLC. Trust or estate. The fiduciary. Privacy Act and Paperwork Reduction Act Notice. We ask for the information on this form to carry out the Internal Revenue laws of the United States. Form 8655 is provided by the IRS for your convenience and its use is voluntary. If you choose to authorize a reporting agent to act on your behalf, under section 6109, you must disclose your EIN. The principal purpose of this disclosure is to secure proper identification of the taxpayer. We need this information to gain access to your tax information in our files and properly respond to your request. If you do not disclose this information, the IRS may suspend processing your reporting agent authorization and may not be able to honor your reporting agent authorization until you provide your EIN. Routine uses of this information include giving it to the Department of Justice for civil and criminal litigation, and to cities, states, and the District of Columbia for use in administering their tax laws. We may also disclose this information to other countries under a tax treaty, to federal and state agencies to enforce federal nontax criminal laws, or to federal law enforcement agencies and intelligence agencies to combat terrorism. You are not required to provide the information requested on a form that is subject to the Paperwork Reduction Act unless the form displays a valid OMB control number. Books or records relating to a form or instructions must be retained as long as their contents may become material in the administration of any Internal Revenue law. The time needed to complete and file Form 8655 will vary depending on individual circumstances. The estimated average time is 6 minutes. If you have comments concerning the accuracy of this time estimate or suggestions for making Form 8655 simpler, we would be happy to hear from you. You can write to the Internal Revenue Service, Tax Products Coordinating Committee, SE:W:CAR:MP:T:T:SP, 1111 Constitution Ave. NW, IR-6526, Washington, DC Do not send Form 8655 to this address. Instead, see Where To File above.